Reducing childhood pneumonia deaths in India: Work in progress

During the Millennium Development Goals (MDG) period, the global under 5 mortality rate declined by more than half— from 90 deaths per 1000 live births in 1990 to 43 deaths per 1000 live births in 2015. India had an estimated 609,000 deaths among children under the age of 5 due to pneumonia and diarrhea in 2010, the highest amongst all the countries in the world.
According to the recent WHO estimates of 2015, 14.9% deaths of children under 5 years of age reported in India were attributable to pneumonia. Excluding the deaths in the neonatal age-group, WHO estimated that 28.4% deaths of children aged 1-59 months in India are due to pneumonia, which is the highest cause of death in this age-group. WHO and UNICEF have developed an integrated Global Action Plan for Pneumonia and Diarrhea (GAPPD) to end preventable childhood deaths due to pneumonia and diarrhea by 2025. The plan focuses on a three pronged approach of Protect, Prevent and Treat. Tackling pneumonia requires emphasis on exclusive breastfeeding for first 6 months from birth, vitamin A supplementation, and reducing household air pollution. This must be coupled with the use of vaccines against measles, pertussis, haemophilus influenzae type b (Hib), along with pneumococcal conjugate vaccines (PCV) in national immunization program. These control methods together can substantially reduce pneumonia illness and death in children. The treatment for pneumonia can be managed with improved care seeking and referral, along with treatment with antibiotics and monitoring of oxygen levels in the child. WHO recommends amoxicillin dispersible tablets as the only first-line treatment for children under age 5 diagnosed with pneumonia.

In India, while there have been improvements on a couple of fronts, a lot still needs to be done. The care-seeking for children under 5 with symptoms of Acute Respiratory Illnesses (ARI) taken to a health care provider was 77% in 2013-14, which is a significant improvement from the 69% reported in 2005-06. However, the point of worry in this case is that while in 2005-06, 80% of children under 5 from the wealthiest quintile sought a healthcare provider, the figures for the children from the lowest wealth quintile was only around 60%. This gap is still large and the corresponding figures for the children from the lowest wealth index was around 74% in 2013-14. The percentage of children under 5 years seeking care in 2005-06 from rural areas was 66.3% against the urban figures of around 78%. The corresponding figures for 2013-14 are 75% for rural children and 79% for urban children. The Government of India has undertaken steps to reduce childhood deaths in the country and the action is evident on multiple fronts. The National Vaccine Policy was introduced in the year 2011, following which the pentavalent vaccine has been introduced in the country from 2014 onwards. This combines the dosages for DPT, Hib and Hepatitis B immunization at the age of 6, 10 and 14 weeks in the country’s Universal Immunization Programme. The Global Health Observatory, a WHO body, has estimated an uptake of around 45% for the Hib vaccination during the past 3 years.

Another front where urgent action is necessitated is that of malnutrition in children, which has a definitive link with childhood diseases like pneumonia and diarrhoea. India has a high burden of malnutrition, 38% of children under 5 years of age were reportedly stunted, 15% of children were reportedly wasted and 30% were reportedly underweight. A reduction in childhood malnutrition will definitely reduce the overall burden of childhood mortality as it contributes to more than one-third of all the child deaths globally. Efforts to tackle the preventable deaths from pneumonia and diarrhoea will have to be sustained to make a significant difference.

The government has been able to reduce the rural-urban gap for care-seeking, for ARI symptoms in children under 5, which was starkly evident in 2005-06. The Ministry of Health and Family Welfare has also initiated the Child Death Review (CDR) in the country— the guidelines for which were disseminated in September 2014. However, a review in 2015 showed that CDR is yet to gain momentum in most of the states except Maharashtra, where effective implementation was reported, and Karnataka where the mechanism was being set-up. The CDR is essential to target the high-incidence areas and will provide better data across inter and intra-state variations, where concentrated efforts may be required. To create an impetus, there has to be a political will from the states as well to uptake such initiatives and bolster the program with state level inputs necessary across the cultural and social diversities across the different states in India.